other things amanzi

call it

2009-07-12T15:48:00.001+02:00

i noticed my use of the phrase 'call it' a few times recently. it is something i saw on american tv and not at all something that is common in my neck of the woods. the sort of scene that you would get in gray's when the junior doctor is pumping the chest shouting 'i will not let you die, dammit!' while the senior doctors stand one side and instruct him to 'call it!' is pretty foreign to our way of doing things. i even got ragged a bit for using the phrase at all. i thought i'd relate a story from days gone by that illustrates this point.

it was the time of the taxi wars. now taxis in our country are nothing like you might be thinking. they are fleets of mini-buses, quite often owned by people of questionable legal character. occasionally rival groups try to take each other out (i mentioned this before here). but roughly at the turn of the millennium there was outright war. when the war came to pretoria we saw quite a few of the victims, but neurosurgery got the most. a friend of mine was rotating through neurosurgery and this story came from him.

there had been a contact between two different taxi organisations. the casualties were streaming in. the neurosurgeon and my friend, his trusty lackey, were overworked and i think it had affected their sense of humour. so while they were getting another gunshot head ready for surgery and heard another four were en route, they were not amused. when the ambulances arrived the neurosurgeon said he wanted to go out and triage them in the ambulances before they were unloaded. and this is what they did.

the neurosurgeon looked at each patient in turn. the first three he told them to send into casualties for his attention. but the fourth...he took one look at the fourth and exclaimed;
"vat hom weg! hierdie een is gefok!*"

my colleague laughed the next day when the newspapers reported;
"on arrival at the hospital, one taxi driver was declared dead by the neurosurgeon on duty." fortunately they did not quote him verbatim.

*take him away! this one is f#@ked!

mopping up

2009-07-11T19:21:00.009+02:00

sometimes before you are even called the sh!t has already hit the fan. the mopping up is not fun.

i was on call. as usual i was hanging around in the radiology suite (i spend a lot of my free time there sharpening up my ct scan reading skills. the radiologists even think i'm a frustrated radiologist, poor fools). the urologist phoned me. he had a nervous laugh. most types of laughs of urologists i quite enjoy. but the nervous laugh i do not. he then went on to tell me about a patient he had been referred with possible kidney stone and severe pain, but on the scan they found a large abdominal aorta aneurysm. i quickly called the scan up on the monitor and sure enough there it was. the patient was mine.

there was an 8cm aneurysm. but just anterior to this there were signs of recent retroperitoneal bleeding. this was not good. the guy was just one step away from a fatal rupture. i phoned my vascular colleague in pretoria who was unfortunately in theater but they assured me he would get back to me in about 20 minutes. then another call came through.
"doctor, the urologist says i must call you about his patient. he says it is now your patient. something has happened." i knew i needed to run.
"i'm on my way!"

as i rushed through the ward i saw what must have been the family. they were all looking anxious and some had tears in their eyes. i rushed on. i needed to focus.

in the patient's room it looked like well orchestrated chaos. lying on the floor was a massive man who was as pale as a sheet. the casualty officer was intubating. a sister was doing cpr. the urologist looked up.
"glad to see you! well then i am no longer needed. see you around." and with that he walked out. someone was trying to place a drip with little to no success. a large group of young student nurses were looking on with expressions ranging from shock to morbid fascination to excitement. i needed to take control. only thing is i had seen the scan and i knew what had happened (when an 8cm aortic aneurysm ruptures into the abdomen it causes almost guaranteed instant death).

i told the nurse to stop cpr long enough for me to check for signs of life. there were none. she continued. i then did some basic tests to gauge brain stem function. there was no detectable brain stem function. i called it right there.

after a dramatic unsuccessful resus there is usually an eery silence in the room. maybe it is a sort of respect for the departed or maybe it has to do with confronting one's own mortality. i think it has a lot to do with thinking who is going to say what to the family.
"are you going to speak to the family?" i asked the casualty doctor. i had to try.
"no! you are!" great! i thought. i walk in on the closing act and i'm left with the hot potato.

i took time to speak to the nursing staff, telling all those directly involved that they did well and just trying to somehow let the students know that it is ok to not be ok with death up close. then i went quiet. i needed to focus.

the family had been taken into the sisters' tea room. they then sent me in. the mopping up had begun.

i have spoken before about breaking bad news. fact is it is never easy and i'm not sure there is any easy way to do it. i try not to leave the family in the dark too long. once they know i try to be as supportive as possible and to answer their questions as best as i can. usually i am struck by the human tragedy and i allow it to affect me as it should. sometimes when i have been overcome by the relentless nature of my work i must stand back and observe. this was one of those times.

strategy

2009-07-09T17:11:00.004+02:00

while i'm on the topic of how to handle consultants i was reminded of another consultant who was somewhat peculiar. also while in prague one of my old colleagues from the old days who actually reads this blog asked why i never wrote about this very interesting individual. so here goes. lets just call him doctor d.

doctor d had dogmatic views on pretty much everything and his views were usually fairly odd. he had developed a way of discussing one or other of his views during operations. he could time a discussion about a given topic to last just long enough that as he placed the last stitch he would wrap up his talk. so with a short operation he would just launch into his theories, but with a longer operation he would start by asking each person in theater what they thought of whatever topic he had chosen for that specific operation. i used to enjoy listening to him during operations and sometimes even felt disappointment when the last stitch would be placed while he said,
"and that is why you should not send your children to school but should home school them." or "and that is why you should always wear long sleeved shirts" or "and that is why cremation is wrong" or some such statement.

but on ward rounds my feelings about these discussions were completely different. an operation had a predetermined end, but ward rounds could go on indefinitely. with this in mind i'd instructed the students how to respond to doctor d so as to shorten the discussion as much as possible. i explained to them that if he asks their opinion about anything not related to surgery he is not asking because he wants to know their opinion, but rather that he wants to expound his own theories. if they gave their opinions he would first take time, a lot of time, to debunk their theories before explaining his own. they were under strict instructions to make sure they didn't give their opinion but rather just immediately ask doctor d what he thought. and then after he had expounded his often bizarre theories the students were not permitted to question him on the rounds. if they wanted to argue some point they could do it in their own time when the rest of us would not be forced to stand there, often post call, and listen too.

generally this approach worked quite well and ward rounds usually didn't drag on more than a half hour after seeing the last patient while we heard why a contraception was wrong etc. that was until one day.

we had just seen the last patient on our post call rounds and ward rounds were as good as over. the students were a new group but i had already orientated them about what to do when asked questions unrelated to surgery. so i didn't worry too much when doctor d started.
"what do you think of rugby?" he asked each student. they dutifully were non committal and quickly turned the question back on him. i was smiling inwardly. we could wrap this up in about 5 minutes if no one questioned him afterwards and he still would be none the wiser i was sabotaging his beloved so called philosophical discussions. he continued.
"rugby is a homosexual game and anyone that plays it must be homosexual." i could almost hear my bed calling. we just had to nod and soon we'd be on our way. and then things went south.

one of the students seemed to be turning slightly red. he also seemed to be bouncing up and down on the spot.he seemed disturbed. i realised he was going to go against my instructions and ask something or worse, challenge doctor d. i started recalculating how long it would take for the rounds to end. but what happened then i hadn't expected.

suddenly the student jumped forward with index finger extended, first towards me;
"i know you forbade us from questioning doctor d about any of his crazy theories, but this i just can't take!" and then towards doctor d:
"doctor d how the hell can you say rugby is for homosexuals? do you really think all the springboks are homosexual?"

i wanted to cry. not only were we forced to endure the full length explanation of doctor d as to why rugby was indeed a homosexual sport, but afterwards i was personally taken to task for instructing the students as to how they were to ensure the good doctor d's talks did not go on for quite as long as he liked them to. worse still, the good doctor d adjusted his way of discussing his theories on ward rounds to bypass my influence on the students. never again did we have a short discussion after rounds, whether the students asked questions or not. doctor d also i think trusted me much less after that episode.

looking good

2009-07-08T01:33:00.003+02:00

the boss was ... well i suppose an interesting man. difficult might be a better description. one of his pet peeves was that his registrars were always to wear a tie and a long white coat. appearance was everything. this demonstrated itself beautifully one day.

i was the most senior registrar. that is why the boss volunteered me to be a sort of backup for the rotating ear, nose and throat registrar who, due to a series of unfortunate circumstances found himself in charge of the friday firm for a weekend. he was clearly out of his depth. i was ordered to do rounds with him and to try to make sure he didn't inadvertently kill someone. so that is what i did.

the saturday rounds went ahead without incident. i was on call on saturday, however, so by sunday morning i was fairly worn out. in all fairness i had had a good uninterrupted two hour's sleep so it could have been worse. i did my post call rounds with my team very early so that i could send them on their way and be ready to help the hapless ent guy. i waited for him in the doctor's tearoom adjacent to the female surgical ward. this is where i kept my white lab coat which i used to ward off the prof's wrath. however on this fateful sunday i took it off just before going on the supervising rounds with our poor rotator. post call i also didn't have a collar and tie, but i had on what i thought was a very smart polo neck jersey. i was on the lookout for the boss because it is better to avoid trouble if you can. then i saw my good friend swimmer's chest. i was relieved to see that he also didn't have a white coat on, although he was particularly smartly dressed.

swimmers chest ambled over slightly slower than usual and greeted me. before i could reply the boss had stormed in with his entire entourage and was breathing down our necks.
"where are your white lab coats?" with him to answer a seemingly direct question tended not to go down well. i tried anyway. it didn't go down well. he let rip and was soon on one of his unstoppable tirades (i have mentioned this before). he told us we looked like hobos and that we set a bad example for the students (quite a few of which were standing behind him to view his example too).

i could feel my anger rising. i wanted to let rip back. i looked over at swimmer's chest. he was looking down and nodding in a submissive sort of way. i remember thinking to myself i must just follow his lead. he would not let the boss get to him and he would not be overcome with anger. i remained as calm as i could.

this went on for some time but each time i though i had had quite enough and just about decided that i was going to tell the prof exactly where he could get off i would glance over at swimmer's chest whose stoic face had not changed a bit. his head remained slightly drooped and he was gently leaning against a bed. only occasionally would he nod in feigned agreement with some of the ridiculous things the boss was saying. i tried to do the same and, at least on outward appearance i think i did pretty well.

finally the prof moved on after a few departing threats. i tentatively breathed again.
i turned to swimmer's chest and smiled. i hoped my smile carried the message that i was thankful that he had helped me remain calm and thereby saved me from doing something that had the potential to be a career limiting move. the poor ent guy looked shell shocked. where he came from this sort of thing just didn't happen.

swimmer's chest looked up as calmly as ever. he smiled broadly as if nothing had happened. after too long a pause he finally spoke.
"the prof had a lot to say about my clothes, but he didn't say anything about the fact that i'm drunk. i've only just got back from a night out."

i fell about laughing. i understood better the events that had just transpired.

kalahari

2009-06-29T22:06:00.004+02:00

after looking at the first world i got a bit contemplative about the point of staying in this god forsaken place. then i was privileged enough to spend some time in the kalahari. my soul was once again restored and i remembered quite a few reasons to stay. here are just a few.
the endlessness went on and on ...well, endlessly.
unfortunately this doesn't even come close to showing what it really looked like.
the kalahari is an interesting desert. although rain is very scarce, it seems to be teeming with life.
a tree with a communal bird's nest.

bell bottoms

2009-06-23T11:10:00.002+02:00

i recently went to prague. what a culture shock. the place is clean and beautiful and safe. i travelled quite a bit on the public transport and not once felt in danger even though i'm south african.

there is generally law and order. on the first day i went on the underground i did not stamp my day ticket because, being south african, i just assumed there would be someone to stop me and check. there was not. they rely on the people there being honest. being south african i rode the whole day essentially for free. then my conscience got the better of me and i bought another ticket so they would not lose money.

you see we south africans have no law and no order. we get away with whatever we can. we all speed and we all jay walk and we all bend all the rules as far as we won't get caught. in prague it is exactly the opposite.

but getting back to the story. one reason it was such a culture shock is because a while ago, to travel on public trains in south africa was quite risky. you see there were gangs that would throw people off moving trains for a laugh. there was also a time when certain trains would get attacked by automatic wielding thugs that would indiscriminately shoot people. these days there is more security (all armed of course) so it isn't quite so bad. there still is the occasional torching of a carriage if it turns up late. let it never be said south africans can't express their anger at trains not being on time.

anyway, while i was safely travelling on the czech (for americans, that is where prague is) public trains, i thought about a few of the patients i had seen. i don't think i'll talk about the guy that got corkscrewed between the train and the platform here. the bell bottom patient came more strongly to mind.

it was in the days of the indiscriminate throwing people off and in front of trains. most died on the scene, but a few got to us. for those who don't know, to get injured on south african train tracks is a sure recipe for sepsis. the trains drop their sewer directly onto the tracks, so to get an open fracture there usually ends up quite a mess. my patient was thrown in front of an oncoming train from the station platform. i suppose the people who threw him there thought it was quite funny at the time. we at the hospital did not.

the poor victim of this senseless crime fell with most of his body over the further track. in fact only one leg lay over the one track. unfortunately he had no time to pull his leg away before the train went over it.

now, to fully appreciate what happened one must realise the patient was fully awake and fully sober. he had in fact started extricating himself when the first wheel cut and mangled his leg about mid thigh. he continued to pull himself away. the second wheel therefore hit his leg about two inches lower down. the next wheel then struck about two inches below that and so on. so the leg was mangled worse than any mangled limb that i have ever seen and more than likely will ever see. it had deep cuts at two inch intervals. the femur was severely broken but it was not nearly as bad as his lower leg. the lower leg spread out like a bloody and distorted bell bottom ending in a very wide flat thing that had once been a foot.

suffice to say he lost his leg that day. (for up and coming south african surgeons, leave the wounds open from train track injuries, like we did. otherwise sepsis will set in and things will get worse.)

so while in prague, i was really confronted by the many acts of meaningless violence we see in our country because i had a clear picture what life could be like in a peaceful place. i honestly wondered what the point is here.

anger

2009-06-22T11:50:00.001+02:00

in the old days sometimes confrontation was the only way to get things done. but sometimes anger lead one into useless and unnecessary confrontation. i recently spent some time with my old friend, swimmer's chest and a story came to mind when that swimmer's chest saved me from my own anger.

we were on call together. quite early in the day the chemotherapist called me. he had apparently put a patient on the emergency list the previous day for a portacath and the case didn't get done. this was due to the fact that the emergency list first did critical cases like actively bleeding patients before they did relatively stable patients. something like a portacath would tend to get shifted down the list and may even stand over to the next day. this is what had happened here. he now wanted me to do the case.

"sure i'll do it" i said. "as long as it's on the list as soon as it comes up i'll be there."
"i want it done now!" he retorted. i was not impressed.
"well phone the anaesthetist on call and motivate for him to move it up the list." i said helpfully.
"that is not my job! you will do that!"

it was clear we had a communication problem. whenever i had a telephonic communication problem i would put down the phone and take the effort to go to the relevant person to sort it out face to face. not only does it help to speak things out in person but the walk usually gave me time to calm down (there was more than enough residual anger in those old days to go around). this is what i did here. i turned to swimmer's chest and told him to accompany me. off we set at speed.

we walked into the chemotherapy ward and asked to see the relevant doctor. soon he was there in front of me. swimmer's chest hung back. i introduced myself and explained that i was more than willing to do the surgery but i had no control over the order of the list. that was entirely in the hands of the anaesthetists. if he felt the case needed to be done before the other cases on the emergency list then he should phone the anaesthetist and discuss it with him.

"you will phone the anaesthetist yourself and you will do this case right now!" he said.
i could feel my anger slowly turning into fury.
"no! you will!" as i said it i clenched my fists and took a step towards him. swimmer's chest realised things were on the verge of going south. he later told me he thought i was going to punch the guy. i denied this, but the thought was going through my mind at the time, i confess.

so my good friend stepped in front of me with his broad chest and nudged me backwards. he then started speaking to the chemo doc in a calm diplomatic voice. he also subtly and slowly (almost so one didn't notice) ushered the guy further and further away from me. by the end of it we left with the chemo guy feeling that we were there for him and would do all we could. i don't think he even had an idea of how enraged he had made me.

walking away swimmer's chest asked me if i was mad. i had only a few month's of training left and something stupid like getting into a fight was just about all that could stand in the way of me becoming a surgeon.

those times in the end brought out the worst in me. by the end of my studies i knew i needed to get away from it all. i had very nearly become something i did not like. after leaving pretoria i gradually rediscovered the true me again. it was still there to my relief.

eccentric

2009-06-08T19:34:00.001+02:00

sometimes eccentricity is excused by brilliance. the old prof of thorax in my humble opinion fell into this category. i quite enjoyed his lackadaisical approach to training, especially because i was not required to know thoracic surgery to the depth that a thorax surgeon was required to know it. i could sit back and observe.

during my rotation in thoracic surgery i enjoyed the morning meetings. the prof was very knowledgeable in all things. truth be told i never heard him teach any thoracics. he taught pretty much everything else. he would walk into the thorax lounge, sit back, light a cigarette and drink coffee. as long as you kept his cup of coffee full he would just keep on talking about all sorts of topics (except thorax surgery. he reasoned the registrars were supposed to be reading current articles and therefore were supposed to be more up to date than he was. if that were the case then how could he be so audacious to assume he had something to teach them?).
he also had what i considered a sort of inappropriate giggle. after almost every sentence he spoke he would slightly lift his shoulders and let out an almost inaudible giggle. no one else dared laugh unless it was clearly a joke. he was, after all the prof.

finally one day i witnessed him giving a thoracic surgery opinion on a thoracic surgery patient. as usual he was sipping and puffing away waxing lyrical about some or other topic which he seemed to be an expert on (i think he was explaining how he had written the program that his department used for patient records or how the cities electric supply was wired). one of the thorax registrars stood up with a ct scan. he placed it on the x-ray board and waited for a gap to ask the prof's opinion. sure enough, after the next giggle, the prof turned to see what he was doing.
"excuse me prof but could i ask you for an opinion on this patient please?" the prof put down his cigarette and coffee mug (which i duly quickly refilled). he then reached into his top pocket where he kept his fold up reading glasses. all eyes were on him as he clumsily unfolded them and placed them precariously on the tip of his nose. he then threw his head back in order to be able to look through the said glasses. everything went silent. then spake he.
"hierdie pasient is gefok!*" followed by a gentle lifting of the shoulders and the usual giggle. he whipped the glasses off his face, folded them up and returned them to his pocket in one smooth movement. i laughed. it seemed i still couldn't tell the difference between the prof trying to be funny and being deadly serious because everyone in the room stopped what they were doing and stared at me as if i had disrespected the great man. i swallowed hard and shut up. after all the prof was exactly right.

*this patient is f#@ked

skande

2009-06-06T17:19:00.002+02:00

let me just start by saying that i personally think joost van der westhuizen may be the best scrum half the world has ever seen and besides possibly advising steve hofmeyr not to add the line "'n blou bul snuif nie van 'n hoer af nie" to his blou bul song because it can't be substantiated, i don't particularly care about the recent media frenzy about the man. i think they should just leave him alone, whether the stories are true or not.

however, after one of my old interns related a story to me many years ago i never viewed him as too bright. i suppose you don't need to be bright to be the best scrum half the world has ever seen.

my house doctor was going out with a rugby mad guy (i suppose a bit like me actually). her boyfriend was a particular fan of joost van der westhuizen (as i was too). one day she was walking through the streets of pretoria when who should she run into but none other than joost himself. she was not a great fan of rugby and by implication of joost but she was quite a fan of her boyfriend. she therefore decided to ask him for an autograph which she would give to her boyfriend and thereby earn many brownie points. the way she tells the story, the exchange went something like this.

"excuse me mr van der westhuizen, but could i please have an autograph?" says she presenting him with paper and pen in order to facilitate the exchange.
"ok, if it doesn't take too long." replies the legend.
"why? do you have a problem writing your own name?"

she did not get the autograph and the associated brownie points. she did, however get a good laugh from me.

ruthless kindness

2009-06-03T10:45:00.002+02:00

in my line of work there is sometimes a fine line between cruelty and kindness. sometimes the line can seem to blur. hang around me long enough and you will probably be shocked at some stage.

the guy had apparently fallen asleep next to his fire. when he rolled over into it his alcohol levels ensured that he only woke up once his legs were well done. someone found him and brought him in late that night.

when i walked into casualties i could smell him. you can almost always smell the burns patients. i took a look. the one leg actually wasn't too bad. it had an area of third degree wounds but they weren't circumferential. i could deal with that later. the other leg, however, had the appearance of old parchment from about mid thigh to ankle right the way around. this could not wait for later.

in third degree circumferential burns, the damaged skin becomes very tight. constricting is actually a better description because unless it is released the taught skin will so constrict the leg's bloodflow that if left untreated the patient's leg will die. it is like a compartment syndrome only the entire leg is the compartment. interestingly enough in third degree wounds all the nerves have been destroyed so in these areas the patient has no feeling whatsoever. that means when we do the release (an escharotomy which is cutting the dead skin along the length of the leg in order to release the pressure and thereby return the bloodflow) no anaesthetic is needed. you just cut the skin and as soon as you hit an area that the patient feels you've gone too far. if you do it right they will feel nothing. the longer you wait the higher the chance that he will lose his leg. i knew what i needed to do. i also knew my students might never get to see this again before they might have to do it themselves in some outback hospital in their community service year.

i asked for a blade and gathered my students around me. i sunk the knife through the dead skin and ran it down the length of the leg. the wound burst open as the pressure was released. the patient didn't flinch. quite a number of the students did. one excused herself and ran out. i think she might have been crying. despite me telling them that it wasn't painful and it was in the best interests of the patient to actually see it was more than most normal people could take.

when i wrote my last post and expressed a form of traumatic stress i found the contrast within myself compared to this incident quite interesting. everything seems to be relative and during the job there will be things that leave scars and many things that traumatise/desensitise us. i was ok doing what that one student obviously thought was gruesome and bizarre because i was convinced it was in the best interests of the patient. when i did this procedure which, on the face of it, is so much more brutal than taking someone to shower, i was ok, but the shower incident was terrible for me. i ended up hoping the student didn't see me as quite that monsterous. i also hoped she would get over the trauma i had inadvertently caused her.

the patient kept his leg.

leaking

2009-05-31T19:22:00.006+02:00

people are basically sacks full of water. the skin keeps the water inside. trust me when i say you want to keep your water inside.

the second post i ever wrote had to do with watching someone with burn wounds fade slowly away. in the end it had more to do with my own mortality. when i read it recently i was reminded of quite a few poignant stories. this is one.

usually things happen in groups and, it seems, burn wounds are no exception. on two successive nights two severely burned patients came in. i got the first. my colleague got the second. my patient had 98% burn wounds (usual story of being doused in petrol and being set on fire. someone didn't seem to like him). only where his hair had been was he not burned. that means that 98% of the sack that is supposed to keep the water in was leaking.

let me take this moment to say that it is not possible to survive 98% burn wounds in any setting. this patient was as good as dead, so whatever we were going to do would only partly help. the outcome could not be changed.

the immediate treatment for burns is to replace the fluid that is leaking out through the wounds where the skin used to be. the amount of fluid one gives is proportional to the surface area burned or the surface area leaking. in 98% that turns out to be quite an amazing amount of fluid. and that is what we did. i worked out the fluid needed, put up a good central line and started running it in. the next day he was still alive.

the next day was when the second burn wound patient came in. he had 95% burns and therefore was leaking pretty much the same amount as my patient. my colleague admitted him, but he treated him differently. my colleague knew that the end of the road was predetermined and didn't see the point in prolonging the inevitable. he only gave him normal maintenance fluid which a normal person would require. he considered more as treatment and didn't see the point in treating something that could not be treated. i considered that he may have a point. i went to see his patient.

his patient was not doing well. the loss of fluid had pushed him into a stuporous state. he didn't seem to have long to go. i left. he died soon after.

my patient remained alive through that day too. because of his wounds he could not lie in bed without extreme discomfort. but the soles of his feet had no skin so he could not stand either. the skin of his hands had all peeled off and they had swollen into useless immoveable paws.

the head of the firm then decided we should take him into a shower and remove all remaining loose skin. i got the feeling he was trying to teach us some sort of lesson. the only thing i learned is that it is brutal to try to remove loose skin, even gently from such a patient. the patient was not having fun at all. i kept thinking why are we making the last days of his life any more miserable than they already are? the head then decreed that we would repeat this process in two days time. i felt sick at the thought. the wisdom of my colleague not treating his patient seemed much clearer to me then.

the next day when i arrived at work i was relieved to discover my patient had finally succumbed to the inevitable. it would not befall us to have to torture him the next day in order that we learned some mysteriouis lesson.

ct scans

2009-05-31T11:26:00.002+02:00

i'm usually quite good at reading ct scans, but this one just left me with one big question mark.

suboptimal

2009-05-29T16:18:00.006+02:00

recently i did a submandibular gland excision. i always find them challenging. i think i know why though.

i was no longer a junior registrar but i still had a long way to go. i had just been rotated to kalafong and it was my first theater list, a list that had been booked by my predecessor and one i therefore did not know. my consultant knew me from a few years before when i had worked in his firm as a junior registrar. as much as he was able to actually have human feelings, i think he almost liked me.

i assisted the first case with the consultant operating. it annoyed me a bit but i assumed he hadn't worked with me for a while and wanted me to get my eye in before he entrusted the knife to me. when he once again took the prime position in the second operation i started wondering if i was to get any operating time in his firm. what could i do?

after the second operation my boss turned to me.
"just a mastectomy and a submandibular gland excision left. have you ever done a submaqndibular gland?"
"no." i answered truthfully.
"have you ever seen one done?"
"only once when i was a fifth year medical student, so it hardly counts."
"i'll give you a very good article describing the technique."
and with that he turned and left.

it was kalafong so he returned long before we got the mastectomy patient on the table. he handed me the article, which he had fetched from his study, told me i'd be fine, and left.

great. i had to somehow quickly read the article between the mastectomy and the submandibular gland and then do the operation with only theoretical backing. i tried to swallow hard, but, in sympathy with the patient's soon to be excised salivary gland, my own salivary glands had simply stopped working. my mouth was suddenly very dry.

so i did the only thing i could. i cut out the offending gland, more or less how the article suggested i should. but somehow to this day, whenever i am asked to do a submandibular gland, my adrenal glands tend to contract a little bit when i think back to my first one.

lights, knife, action

2009-05-24T18:05:00.000+02:00

i was reading a post by a really good medblogger i follow. it reminded me of an incident years ago when i was rotating through neurosurgery.

now neurosurgery lends itself to tracheostomies (long intubations in people who tend to not want to breathe on their own). i soon became pretty good at an icu unassisted trache (that was the way we did them then). then the new guy arrived.

the new guy was a rotating orthopod. the neurosurgeons knew i would be leaving soon and their reprise from doing all their own traches would come to a sudden end. when the orthopod expressed interest in learning the procedure they saw an opportunity and quickly appointed me his teacher. as usual there were a couple to do that day. i'd do the first and he'd do the second. then he would be on his own.

the demonstration trache went well. i tried to point out all the tricks i'd learned with the thirty or so tracheostomies i'd done. he watched in silence, occasionally nodding his head in acknowledgement. and then it was his turn.

we walked together to the outlying icu where our next patient was. there were quite a few icu units in that hospital. when the neurosurgical icu was full any new neurosurgery patients could find themselves landing in one of any number of outlying icu units. generally these weren't quite as geared for neurosurgical patients but they were good enough.

finally my young apprentice put steel to skin. immediately i realised this guy had a natural acumen for surgery. he seemed to intrinsically know what to do. his movements were precise and achieved exactly what was intended. he definitely didn't need any advice from me. there was only one thing not right.
"sister, please call the anaesthetist on call." the orthopod stopped dead in his tracks. his head shot around to look at the monitor. as soon as he confirmed the patient was stable his head swivelled back to stare at me almost accusingly. then he got back to work. he knew there was basically no way an anaesthetist in that hospital would actually come out of theater, much less to make the long trek up to this out of the way icu. and if he did come all the way, it better be to miraculously raise someone from the dead. anything less would be beneath the gas monkeys of that hospital.
"sister, please call the anaesthetist on call!" i repeated. she also could not believe me, but dutifully moved towards the phone.
"why?" she asked as she lifted the receiver.
"the lights are not right. tell him to come and position them for us please."

again the orthopod stopped operating, but this time it was because his body was convulsing with waves of laughter.

the patient is gasping

2009-05-17T18:40:00.001+02:00

in the old days at kalafong (hell), the sentence 'the patient is gasping' was euphemistic for the patient is stone dead, rigor mortis has set in and we accidentally found the body when someone noticed a strange smell emanating from his bed. fortunately, occasionally one is pleasantly surprised. one such time was in my first year as a registrar.

he was a young man. with a bit of dutch courage on board he had not maintained a good following distance behind a car while driving home late at night on his scooter. in other words he drove full speed into a parked car on an otherwise deserted road. when i saw him for the first time he was in trouble. his abdomen was distended and painful. his blood pressure was down and his heart was racing. he needed surgery and fast.

just as i was pushing the patient into theater his mother called me aside to ask about his chances etc. i gave my honest assessment with emphasis on the fact that we needed to get going as soon as possible to optimise his chances. then, as if i wasn't nervous enough being such a junior registrar with the prospect of trying to pull this guy through , the mother gave me a small piece of information that pushed my heart rate up to about the same as the patient's.
"he is dr w's cousin." dr w was the most senior registrar in our department.
"good!" i said. but 'oh f#@k' is what i thought. and then i went in to operate.

the operation was a major challenge. in the end i resected segments six and seven of the liver. actually i just scooped them out. the impact had done all the actual dissecting. i just needed to control the bleeding, which in itself was not all that easy. finally we got him off the table in a fair to good condition. after tucking him into bed in the ward i got on with the rest of the call. finally i got to sleep at about two thirty in the morning.

at four in the morning, the phone in the call room rang.
"doctor, the patient is gasping!" my blood went cold. i confess i had images of dr w taking me apart for letting his cousin die. i paniced a bit. i phoned my house doctor and told her to meet me in the ward. then i ran.

i walked in to see something i think i am the only person ever to see in kalafong, an actual attempt at a resus by the nursing staff. the patient wasn't dead, only dying. i was so relieved. then i realised if i let him die dr w would still eat me alive. i jumped to it.

after a bit of the old pounding on the chest, a tube down the wind pipe and much intravenous fluid. we pulled the guy back from the brink and put him in icu (intensive scare as we called it).

and so a near disaster was averted and for once at least 'the patient is gasping' actually meant the patient is gasping.

one shouldn't laugh, but ...

2009-05-12T02:00:00.002+02:00

when i wrote the third principle, i was reminded of another incident. then i couldn't laugh. now i shouldn't.

i was working a casualty shift in a private hospital to make a bit of extra money (a registrar barely made enough to survive). it had been a standard night of treating the aches and pains of people who had been sick for weeks but had decided that once the sun set on friday evening they could no longer endure. maybe they just wanted to torture me.

anyway, finally a real casualty case came in. it was a young lady who had fallen and hit her head. she was fine except for an unsightly gash on her forehead just at the hairline. i prepared to clean and suture the wound. being a state doctor i had hardly sutured any face wounds on sober people, so i remember telling myself to make a point of chatting to her during the procedure to ease her fears. usually good old ethanol did all the fear easing and i was left to my own thoughts while placing the sutures.

so there i was at the head of the patient being as friendly as i could. i'd cleaned the wound and had placed the first suture. the second was going in when an ambulance pulled up. two paramedics brought a guy in on a stretcher. i had my back to them so i wasn't really watching them too closely. then the sister shouted,
"this man is not breathing!"

i left my suture just where it was and ran. as i changed my gloves the ambulance men were asking the patient to shift to the next bed. he wasn't listening to them. they seemed indignant. the sister grabbed him and dragged him over as i arrived.

there was no sign of life whatsoever. he was extremely pale. his trousers were bloodied. he had no drip. we commenced a full resus. after going through all the motions, i called it. the man was dead. i then looked over his body. he had a massive laceration in his groin. his femoral artery was visibly transected. that could be why he didn't respond when the ambulance chaps had asked him to move across to the resus bed. i asked my usual question.
"when you picked him up, was he bleeding?"
"no." they answered. that is why they didn't put up a drip, apparently.
"was there blood at the scene?"
"yes." the one man replied. "he was lying in a puddle of blood."
"was it maybe about five liters of blood?" i wondered aloud.

the leroy-burnell syndrome

2009-05-11T07:24:00.005+02:00

when we were in medical school as with all medical students we were bombarded with many new words. not the least of these were the myriad of syndromes. and each syndrome had symptoms that overlapped with pretty much every other syndrome. it was one large conglomeration of new words all mixed together.

but there were a few other things we noticed. firstly every syndrome worth its salt had a double barrelled name with a hyphen in between. exotic sounding names worked better than simple names like mark or john. also the more symptoms associated with a syndrome the better the syndrome was.

and thus we invented the leroy-burnell syndrome. the name was perfect. and seeing that we used it to explain any conglomeration of symptoms that we could not otherwise bring to a diagnosis, any symptom known to man could be attributed to our neologistic syndrome. (if only house md had known about this syndrome the episodes would all be half the length.) if we had no idea about a patient, my clinical partner would lean across and say,
"this is a classical case of leroy-burnell syndrome." and doff his head intellectually. if the prof was not looking we would laugh.

then one day we were doing our usual ward chores in internal medicine. a group of fourth years came in with a rotating consultant. the consultant lead them to a patient. he told them to examine the patient and make a diagnosis. he would be back in 30min to discuss the case with them.
as fourth years generally were they seemed a bit nervous about direct patient contact. finally they drew the curtain and one approached the patient.

it was about then that my clinical partner decided to 'help'. he stuck his head through the curtain and said.
"you guys, this patient has the leroy-burnell syndrome so make sure you don't miss that. but don't worry, the clinical signs are easy to pick up. good luck!"

the gratitude on the nervous face of the fourth years was clear as they simultaneously thanked my friend for his kind gesture and reached for their pocket references to look up the leroy-burnell syndrome. it seems they hadn't come across it in their studies yet.
i turned away to hide my laugh. i was imagining the pride on the unsuspecting face of the fourth year when he announces to the consultant that this was a classic case of leroy-burnell syndrome.

surgexperiences 222

2009-05-03T00:01:00.002+02:00

surgexperiences 222... short and sweet.

a masterpiece by a master writer. surgeons sometimes don't allow the facts to get in the way of their hard headedness.

stupid excuses awarded.

a hospital's big five.

will boyle-o-phobia be overcome?

something off the wall. a surgeon involved in a famous controversy. i think it's monsterous.

we all make mistakes. only in surgery the stakes are higher.

a bit of lap chole fun.

buckeye helps us remember to not mess around and get back to basics.

a bit of a look at transplants.

a day in the life of a surgeon in sri lanka.

a very impressive story about minimally invasive surgery.

nightclubs remind some surgeons of lower anterior resections (for rectal cancer).

better robotic prostate surgery.

social media sites for nurses.

the surgeon and the torture memos. a must read.

patient denial leads to doctor compassion fatigue.

some people are stupid enough to try short cuts to beauty.

not something to stick your tongue out at.

a very personal look at esophagus cancer.

hairball links to bezoars.

twitter your pituitary adenoma away.

classic svc syndrome.

short link to fourniers.

beautiful laparoscopic pancreas resection.

the plucking of a mass.

a patient's points on gynecomastia.

and that's it. short and sweet. the next edition of surgexperiences will be at notes of an anesthesioboist. for eager future hosts, please contact jeffrey, the guy who runs the show.

host

2009-04-28T11:25:00.000+02:00

once again i'm to be given the privilege of hosting surgexperiences. so please everyone start submitting immediately via this form.

surgical principle number 8: we do it to impress the chicks

2009-04-26T07:08:00.008+02:00

what is the point of even having surgical principles if you can't finish them off with a light hearted one.

general surgery is roughly divided into two categories. ie. blood and guts. the guts side of things involves feces, stomach content, bowel content, bad smells and the like. the blood side of things is often high drama and adrenaline and is the stuff that the medical tv shows are made of. most of the general public don't really want to hear about the time i did a rectal examination and my glove broke or the fact that the smell of a septic abdomen somehow seeps through the gloves and it can't be washed off your hands afterwards leaving a most unpleasant stench. i considered trying to market whatever it is in abdominal puss that causes that stench as a deterrent for fingernail biting, but it seemed too much effort.

but if you talk about someone bleeding to death and you intervene, this causes an entirely different reaction. it makes school children who watch these tv programms think that they would love to become surgeons. i just hope they don't bite their nails. so, bearing in mind we can only really be glamorous in half of our work, it is sometimes nice when one can get a bit of this glory.

it was post intermediates and i tended to stroll around casualties as i have mentioned before. a good friend of mine and i were in the same firm, so the night in question, we were both together checking out what was happening there. we had nothing better to do for a change.
as we casually walked through casualties (why can't more people be casual in casualties i wonder) we heard a bit of commotion in resus. we walked over and glanced in. what a sight.

there was a guy lying on the table. he had a large gash in his chest just left of the sternum. out of this hole bright red blood was gushing out in torrents. there were two casualty officers poking away with artery forceps but in that amount of blood it was clear they were losing the battle badly. the patient was still moving but his movements lacked conviction and were getting weaker as we watched. obviously they had called the thoracic guy but just as obviously, unless he was just around the corner the patient would be dead when he arrived. i thought that the heart was probably lacerated.
i turned to my friend.
"shall we?" i asked.
"why not?" he replied. and we walked in.

the casualty officers acknowledged our presence with nervous smiles. i asked for a knife. there were only loose blades. i took one and extended the wound. the patient didn't flinch. he was on his way out. i shoved a swab in. my friend hooked the edge of the wound with a retractor, but because of the ribs we couldn't really open too wide.
"i see it , i see it!!" he shouted. he reached for an artery clamp and grabbed the upper end of the transected internal thoracic artery (also known as the internal mammary artery, but because this guy was a guy i've decided to go with internal thoracic). immediately the amount of blood was less. i shifted my retractor and quickly identified the lower end of the transected artery. it's a lot easier when you know what you are looking for. i clamped it. soon we were tying the bleeders off.
we spent a bit more time to put up acceptable lines and call theater to book the thoracotomy for when the thoracic guy actually did turn up.

in just moments we had turned a hopeless situation into at least a salvageable one. when the thoracic guy finally did turn up all he had to do was wait for theater and fix up the hole in the guy's chest (which admittedly we were more than partly responsible for).

then my friend turned to me.
"have you seen outside resus?"
"what do you mean?" i asked.
"go look."
i walked outside. there were about five nursing students, all wide eyed and all looking at us as if we were absolute heroes. being a surgeon and already being under the influences of an over active ego, i felt pretty good. i did not want to be the one to tell them we had just been lucky with the injury and that a true stab to the heart would most likely not have turned out quite so rose coloured (except maybe a blood red rose of course).

surgical principle number 7: break the tension, don't add to it

2009-04-22T20:18:00.006+02:00

sometimes surgery is routine and mundane. but sometimes it is anything but.

i have assisted enough surgeons who lose their cool at the drop of a hat to be able to see first hand that it doesn't help. however i only formulated this as a principle when something happened while i was operating as a senior registrar.

it was late at night or in the early hours, i can't quite remember. the case was tense enough in that some guy had taken a standard dose of lead through the abdomen. (this is not the best route of administration. it can be messy.) we had gotten him to theater fairly quickly by that hospital's standards and were systematically going through the things you need to systematically go through. my assistant was a junior medical officer. the scrub sister was also quite junior. i was quite at home with this state of affairs. in fact everything was moving along quite smoothly.

then something went wrong. it involved bleeding and the potential of bleeding in great quantities. my mindset changed instantly. i went silent. my assistant, although he was junior, could see this was not a good situation we found ourselves in. the sister was deeply involved in a conversation with the floor nurse. i think it had something to do with a recipe for chicken feet and atchar. i was glad i had something else to concentrate on. (both chicken feet and atchar are disgusting to me and even to be exposed to a conversation about them i find a bit disturbing.)

anyway i asked for artery forceps (i think that is the translation for arterie klem which is actually what i asked for). i needed them at exactly that moment because it was at that split second that i had perfect exposure and could see the source of the bleeding. the sister hadn't yet realised that the operation had just changed into a new gear. there seemed to be some discussion about exactly what type of atchar goes best with chicken feet and she simply was no longer really into the operation. my assistant snapped.
"sister pass the blasted artery forceps right now dammit!!!" he shouted. it was time for a moment.

i shoved a swab into the wound and applied direct pressure. i informed my assistant that he needed to take a moment too. i then turned to the sister and calmly told her that things had gone ever so slightly south and i needed her to leave chicken feet and atchar for later and pay attention for now. and then... then i leaned over and said the first harsh thing i had ever said to anyone in theater. i told my assistant in no uncertain terms that he will never ever raise his voice at anyone while working with me again. in fact i informed him that while working with me he could only speak directly to me from then on. he was surprised seeing that he thought he was trying to help. (only one other time have i raised my voice in theater and that was to blind chicken boy. but that story could be left for another post)

after the moment i got control and finished the operation to almost deafening silence.

later i discussed the situation with him. at that moment there was too much chaos. there were too many variables working against the patient. my complaint with him had to do with that he heightened an already tense situation and only succeeded in showing the sister that he had no control. i explained that he had to transcend the situation and not only take control, but calm the situation. in surgery you don't need to look for trouble or create it. trouble will come of its own accord.

also as a typical surgeon i was not at all impressed that he had attempted to take control during an operation, but that i just kept to myself.

surgical principle number 6: take a moment

2009-04-14T22:20:00.002+02:00

you wouldn't think it by reading this blog, but sometimes in surgery things can go wrong. and sometimes they can go severely wrong very quickly. strangely at the moment of disaster it is not always clear if you are facing a problem or a full blown disaster. and thus i learned to take a moment.

the principle of the moment actually took its origins from many years ago when i was still a house doctor. in those days i was already doing certain surgeries which were way above my head. i would always try to get my frame of mind right while scrubbing. i would think about the operation and what i was likely to encounter and just try to focus. yes, in a certain sense i was already taking a moment.

in training when i was a junior i did quite a bit of assisting as can be expected. when things got rough generally the tension was almost too much to bear. and if the lowly assistant didn't hold the deaver retractor just right or for long enough all hell was likely to break loose. let me just use this moment to mention that the deaver was designed by a sadistic internist who now sits in his office chuckling to himself about the hand spasms that his instrument causes to us surgery folk. either that or the devil himself took time off from tormenting the damned to create something that could torment the living too.
anyway, as an assistant during those numerous tense moments my hands often spasmed so badly that it was difficult to open them afterwards. i wondered why the blasted surgeon couldn't just take a moment so the poor assistant could stretch his fingers before the next protracted attempt to get whatever surgical control needed to be gotten. at least then at the crucial moment the assistant would be worth something.

and then there is the small issue of bleeding. yes, boys and girls we have learned that all bleeding stops, but i personally believe it is better to stop the bleeding while there is at least a flicker of life left in the patient. these moments are the true adrenaline moments in our job. during these moments the actions of the surgeon will determine whether the patient lives or dies. you need to be at your best. you need your assistant to be at his best. what an ideal time to take a moment. you can just go through what to do in your mind before the chips really do go down. you can instruct your assistant to relax and prepare to unrelax during what is about to transpire while you settle yourself and concentrate on what you are about to do. (it is important to tell the assistant to take a moment. all but the most useless can feel the tension and will not relax unless they are actually told to.)

but the moment has to do with bleeding too. obviously you can't just step back while some big artery is pumping blood all over the floor (it might annoy the sister). pressure is the key. you put pressure on the bleeder with a swab and then you take your moment. (remember to let your assistant know this is his moment too. he will use it to stretch his fingers and curse the fiend who designed the deaver.) while you are trying to remember the punch line of some weak joke in an attempt to put everyone at ease, your pressure with the swab will help with the bleeding. it is controlling all the venous oozing, leaving only the surgically significant bleeding for you to control. you see in the heat of the moment, with severe bleeding, those worrisome venous oozers sometimes cause just enough trouble to really make control difficult. you are not sure what to tie off and that small amount of ooze obscures the vision just enough to make control difficult.

so in conclusion, at the most critical times during an operation, put time aside to take a moment. it settles your nerves, optimalizes your assistant and helps with bleeding. it also creates the illusion that you are totally in control even if the situation is spiralling downwards towards the creator of the deaver.

surgical principle number 5: it is in fact always the surgeon's fault

2009-04-11T19:00:00.000+02:00

one of my professors used to say, in jest i believe, but i'm not sure, that no matter what goes wrong in an operation, it is always the assistant's fault. i used to give the appropriate awkward laugh. it soothes the fragile surgical ego. but my laugh was never more than awkward.

i somehow could not adopt my prof's opinion. the more i thought about it, the more i disagreed. in training, your assistants are almost always students and pretty clueless. as it turns out, you need to direct them to do what you need them to do. you actually have to actively use them as additional instruments in whatever operation you happen to be doing. besides, at the m and m, it will be you and you alone before the prof when he asks the obligatory please explain.

bearing in mind most students have a dread of the surgery and bearing in mind some of the stuff that goes down can rest heavily on the conscience (and therefore your sleep) i'm not sure what advantage there is to let the poor students feel more responsible than they are. in a certain way this principle goes with 4. not only did i try to let my students enjoy surgery, i tried to protect them from some of the trauma which can be inflicted by being so intimately involved with human suffering.

fairly recently my belief in this system was somewhat put to the test. a good friend of mine was assisting me with an appendix. he is destined to become a great internist one day which sort of implies he could sometimes be somewhat absent minded with the physical practicalities of an operation. it didn't bother me. i enjoyed working with him and i reasoned i needed to be fully in control anyway.

with this appendix, every time i asked him to loosen the artery clamp as i tied off the mesoappendis he did some sort of weird hand exchange to be able to loosen the clamp with his right hand. it seems he was not capable of doing it with his left hand. easily solved, i thought. it is true the clamps are all made for right handed people and there was a specific left handed technique needed to loosen the clamp. i decided to teach him this technique. i stopped the operation and asked the sister for an artery clamp.

even though at heart he was an internist, he was a quick learner and quite soon he was easily loosening the demonstration clamp with his left hand. i had a moment of pride in him but it passed soon.

then we got back to work. he grabbed the clamp on the appendix base, the only remaining clamp holding the appendix up to the wound and with a swift smooth movement, released it. the stump slipped easily back into the abdomen. he seemed so proud, i almost didn't want to tell him that usually one ties off the appendix base before the assistant loosens the clamp and allows the appendix to fall neatly into the abdomen. somehow there is less leakage from a closed stump than an open one. but i had to.

we took quite a while longer to retrieve the stump and tie it off and then obviously to do the necessary lavage.

still i had to be true to my principles. yes, even then it was my fault.

surgical principle number 4: enjoy

2009-04-04T23:17:00.004+02:00

surgeons are too stuck up. just because you might be saving someone's life and just because blood and guts might be all over the place it doesn't mean you can't take a moment to just enjoy it all. to be honest it might be the one thing that keeps you sane through all the madness.

in our department the prof demanded complete silence during operations. he even used hand signs to ask for instruments so he didn't have to speak. woe to any student who spoke. and if we didn't show due awe at all times he was not impressed. but the problem with spending so much effort working up all that awe all the time was you were often not left with enough energy to just enjoy what was going on. he also had an amazing ability to make students hate their surgery rotations. (how weird is that? it's like hating ice-cream or christmas lunch). i thought another approach would be better.

there is a general shortage of general surgeons in south africa. sure it has a lot to do with the hours and working conditions and all the other well publicised reasons. but it also has to do with a reluctance to go through the old style training. but i don't think all the aspects of the old style training are bad if you want to create surgeons that are worth something in the real world. but at least instill in them an enjoyment in what they do. i mean, let's face it, how cool is it to be a surgeon? we get to cut people open and mess about a bit with their innards. sometimes we might actually make a difference.

so whenever i operated with students one of the things i concentrated on was instilling in them the absolute joy of surgery. i know of three students that decided to study surgery as a direct result of working with me and one student who decided not to quit medicine altogether after having worked with me.

so for all my faithful readers, whenever cutting and dicing, stop and reflect for a moment about how wonderful it is to do what you are doing. don't just enjoy it but instil in those around you more than just a healthy dose of enjoyment.

surgical principle number 3: all bleeding stops

2009-03-31T21:34:00.007+02:00

this is not originally my principle, but it is so true that it somehow found its way into the surgical principles of bongi.

i first saw this principle in action many years ago when i was a community service doctor in qwaqwa. i was doing a call in casualties. actually, the way it worked there meant i was doing more than just a casualties call. i was also the anaesthetist on call and the overall backup for the two interns. for any big surgery we'd call the cuban surgeon out. otherwise we were it. the interns would do the caesarian sections. i would dope the patients and resuscitate the baby if needed. the interns would also do the debridements and ectopics. here i would dope and give useful advice about what to cut off and out and how. anyway i digress.

one of the hospitals that referred to us phoned. the guy had a stab wound neck. he told me it was bleeding profusely and he wanted to send it for surgery. i naturally accepted the patient. but i told him to somehow apply pressure to the wound to control the bleeding for the trip (his hospital was about 40 minutes away). i actually suggested he send someone with a bit of savvy who could put their finger in the wound to directly stop the bleeding.

once i had gotten off the phone i got casualties ready for a big resus. in qwaqwa this took some doing. the charge sister had to unlock the cupboard where the drip needles were kept (they tended to go missing leaving the hospital with no means to put up a line). i checked the intubation equipment and discovered the batteries in the laryngoscope were not working. this resulted in a protracted search through the hospital for either batteries or another laryngoscope. finally we found a working one. i soon gave up on getting a working defibrillator, although some nurses said they heard there was one somewhere on the second floor. i then phoned the surgeon to give him a heads up. he told me to phone back once the patient arrived. then we waited.

about an hour after the initial call, an ambulance came tearing in. the paramedics jumped out and came rushing in with a patient on a stretcher. the patient was tubed. one paramedic was bagging him. another was giving chest compressions. but there were two other things i noticed right away.

the first was that the neck wound was open with no clear signs of any attempt made to stop the bleeding. the second was that the patient was not bleeding.
"when you left the other hospital, was the patient bleeding?" i asked.
"yes!" replied the guy pumping the ambubag. "he was bleeding like crazy!" he seemed to be the one in charge.
"and when did he stop bleeding?"
"about five minutes after we loaded him."

i called it right there, thereby saving everyone a whole lot of paperwork.

and thus i learned that all bleeding stops....eventually.